Provider Demographics
NPI:1417914094
Name:RYAN, MARIE (CNP)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 1574
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1574
Mailing Address - Country:US
Mailing Address - Phone:575-628-1614
Mailing Address - Fax:575-234-0591
Practice Address - Street 1:101 S CANAL ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5713
Practice Address - Country:US
Practice Address - Phone:575-628-1614
Practice Address - Fax:575-234-0591
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00172363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00NM01R94XOtherBCBS
NMQ5228Medicaid
NM000Q5228Medicaid
NMP00946801OtherRR MEDICARE
NMP00946801OtherRR MEDICARE
NM000Q5228Medicaid
NMNMA101377Medicare UPIN